ASC Tab

Use the ASC tab on the Medicare OP reimbursement tool to define the following pricing methodologies:

Fee Schedule Pricing – Used for ASC pricing by fee schedule using the 2007 and earlier methodology.
Ambulatory Surgery Center (ASC) Pricing – Used for ASC pricing using the 2008 and later methodology.

Note: Refer to the contract to determine the options to select and the values to enter.

The following process is recommended when defining Medicare OP reimbursement terms for managed care contracts:

Use the default settings unless the contract specifically indicates otherwise.
Price claims and look for patterns (such as E&M paying, with or without Mod-25), and then adjust the tool to eliminate those payment variances.

Field Descriptions

The following outlines the fields within the ASC tab of the Medicare OP reimbursement tool.

Fee Schedule Pricing

This section of the reimbursement tool is used for ASC pricing by fee schedule, using the 2007 and earlier methodology.

Field	Description
Fee Schedule ID	The ID of the fee schedule you want to use. If you leave this field blank, the reimbursement tool defaults to the 2007 Medicare National unadjusted fee schedule.
Multiple Procedure Discount	Indicates whether multiple procedure discounts differ from the standard Medicare discounts. To accept the displayed Medicare defaults, leave this check box unselected. To set different multiple procedure discount percentages, select this check box and enter the percentage amounts in the following fields: Highest Paying Procedure – The percentage at which the highest paying procedure is paid. Second Highest Procedure – The percentage at which the second highest paying procedure is paid. Third Highest Procedure – The percentage at which the third highest paying procedure is paid. Fourth, and Other – The percentage at which the fourth highest paying procedure and all subsequent procedures are paid.
Use CCI Edits	Indicates whether CCI edits are run before pricing. This option is rarely selected. Select this check box only if the contract specifically states that CCI edits should be run prior to pricing.

Field

Description

Fee Schedule ID

The ID of the fee schedule you want to use. If you leave this field blank, the reimbursement tool defaults to the 2007 Medicare National unadjusted fee schedule.

Multiple Procedure Discount

Indicates whether multiple procedure discounts differ from the standard Medicare discounts. To accept the displayed Medicare defaults, leave this check box unselected. To set different multiple procedure discount percentages, select this check box and enter the percentage amounts in the following fields:

Highest Paying Procedure – The percentage at which the highest paying procedure is paid.
Second Highest Procedure – The percentage at which the second highest paying procedure is paid.
Third Highest Procedure – The percentage at which the third highest paying procedure is paid.
Fourth, and Other – The percentage at which the fourth highest paying procedure and all subsequent procedures are paid.

Use CCI Edits

Indicates whether CCI edits are run before pricing. This option is rarely selected. Select this check box only if the contract specifically states that CCI edits should be run prior to pricing.

Ambulatory Surgery Center (ASC) Pricing

This section of the reimbursement tool is Used for ASC pricing using the 2008 and later methodology.

Field	Description
Override Provider Number	Preferred provider number. Up to ten alphanumeric digits.
Override Service Date	Preferred service date. Use MM/DD/YYYY format. Temporarily sets the service date on the claim with the date you enter.
Component Pricing
Surgery Procedure	Percentage at which surgery procedures should be priced. This percentage can be between 0 and 500 percent and can be a percentage of the calculated Medicare fee or a percentage of charges.
Diagnostic Imaging	Percentage at which diagnostic imaging should be priced. This percentage can be between 0 and 500 percent and can be a percentage of the calculated Medicare fee or a percentage of charges.
Drugs	Percentage at which drugs should be priced. This percentage can be between 0 and 500 percent and can be a percentage of the calculated Medicare fee or a percentage of charges.
New Tech Intraocular Lens (NITOL)	Percentage at which New Tech Intraocular Lens (NITOL) should be priced. This percentage can be between 0 and 500 percent and can be a percentage of the calculated Medicare fee or a percentage of charges.
Items Priced by Payor	Percentage at which items not priced by Medicare should be priced. This percentage can be between 0 and 500 percent and can be a percentage of the Medicare fee schedule or a percentage of charges. Typically, items not priced by Medicare are priced at a percentage of charges. If the contract indicates that items not paid by Medicare should be paid by invoice, select 100% of Medicare. This prices these items to $0.00 so they can be identified for invoicing at a later time.
Prices Status Indicator (SI)=N1 at	Indicates whether items that are covered, but not paid separately by Medicare (status indicator of N1) should be priced. To price these items, select this check box and enter the percent of charges at which they should be priced.
Price Lines with No CPT at	Indicates whether lines without CPT codes should be priced. To price these items, select this check box and enter the percent of charges at which they should be priced.
Exclude Devices from Surgery Pricing	Indicates whether devices such as implants should be excluded from surgery pricing so they can be priced separately by invoice.
Disregard line item date of service (LIDOS) for Drugs and Diagnostic Imaging (D.I.)	Indicates whether the Medicare rule that requires drugs and diagnostic imaging to have the same date as the surgery should be disregarded. Select this check box if this date of service restriction should be disregarded for a managed care contract.
Change Multiple Procedure Discount Rates	Indicates whether multiple procedure discounts differ from the standard Medicare discounts. To accept the displayed Medicare defaults, leave this check box unselected. To set different multiple procedure discount percentages, select this check box and enter the percentage amounts in the following fields: Highest Paying Procedure – The percentage at which the highest paying procedure is paid. Second Highest Procedure – The percentage at which the second highest paying procedure is paid. Third Highest Procedure – The percentage at which the third highest paying procedure is paid. Fourth, and Other – The percentage at which the fourth highest paying procedure and all subsequent procedures are paid. Selecting this check box automatically clears the Never Discount Multiple Procedures check box.
Multiple Procedure Discount All Lines	Indicates whether multiple procedure discounts should be applied to all surgeries. Medicare excludes some surgeries from these discounts. To apply these discounts to all surgeries for a managed care contract, select this check box. Selecting this check box requires you to select the Change Multiple Procedure Discount Rates check box. Selecting this check box automatically clears the Never Discount Multiple Procedures check box.
Ignore “From-To” Rule for Line Items	Indicates whether the Medicare rule that requires all line items on a bill to have dates of service between the “From” and “To” dates should be disregarded. Select this check box if this date of service restriction should be disregarded for a managed care contract. If you select this check box, you must also select the Disregard line item date of service (LIDOS) for Drugs and Diagnostic Imaging (D.I.) check box.
Never Discount Multiple Procedures	Indicates that multiple procedure discounts should never be applied. To prevent these discounts from being applied to any surgery for a managed care contract, select this check box. Selecting this check box automatically clears the Change Multiple Procedure Discount Rates and Multiple Procedure Discount All Lines check boxes.
Apply Modifier 22	When selected, indicates that a claim billed with modifier 22 on a line reimburses at 120% of the expected reimbursement
Apply Modifier 52	When selected, indicates that a claim billed with modifier 52 on a line reimburses at 50% of the expected reimbursement
Apply Modifier 53	When selected, indicates that a claim billed with modifier 53 on a line reimburses at 30% of the expected reimbursement
Apply Modifier 54	When selected, indicates that a claim billed with modifier 54on a line reimburses as follows: 70% of the expected reimbursement if the HCPCS code has global days of 090 80% of the expected reimbursement if the global days on the HCPCS code is 010

Apply Sequestration Reduction

Field	Description
Apply sequestration reduction	Provides the option to apply the 2% Medicare sequestration reduction to that contract. Note: This option does not affect the calculation of co-payment amounts.

Field

Description

Apply sequestration reduction

Provides the option to apply the 2% Medicare sequestration reduction to that contract.

Note: This option does not affect the calculation of co-payment amounts.

Cap ASC Payment at Line Charges

Field	Description
Cap ASC Payment at Line Charges	This check box option defaults to unchecked. When selected (checked), this option applies payment logic that uses the CPT fee schedule amount, applies modifier, or applies multiple procedure reductions and then caps to line charges with a message code for each line being capped

Always Price as Acute OPPS

Field	Description
Always Price as Acute OPPS	This check box option defaults to unchecked. When selected (checked), this option calculates per APC logic as an Acute OPPS provider to accommodate ASC facilities which negotiate Acute OPPS payments.